Despite the reliance on safety auditing within organizations, comparatively limited research has studied the performance of safety auditing. When an investigation laments the “lack of audit quality” following an accident, what is meant by this statement? What contrasts a “good quality” audit from a “poor quality” audit? This study examined counterfactual logics (statements about alternative realities that did not occur but “could have” according to investigators) within 44 major accident reports to assess how audits are supposed to function and how they fall short of the ideal model. The content analysis yielded nine counterfactual auditing failures grouped into four categories. Contrary to the “ideal” model, audits (a) failed to facilitate an accurate understanding of threats by misinterpreting their saliency, (b) failed to facilitate timely action against threats by inadequately addressing the deterioration of known issues, (c) failed to facilitate effective management of issues, leading to confusion around the purpose and scope of audits, and d) failed to facilitate sufficient focus on threats by lacking focus on critical hazards and focusing on paperwork over operational issues or “failing silently” by missing threats while simultaneously praising performance. Practitioners should critically evaluate audits against these criteria and ensure audits effectively identify early warning signs.

中文翻译：

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根据事故调查，审计如何失败：反事实逻辑分析

尽管组织内部对安全审计的依赖，但对安全审计绩效的研究相对有限。当调查在事故发生后感叹“审计质量不足”时，这句话是什么意思？“高质量”审核与“低质量”审核有何不同？这项研究检查了 44 份重大事故报告中的反事实逻辑（根据调查人员的说法，关于未发生但“可能”发生的替代现实的陈述），以评估审计应该如何运作以及它们如何达不到理想模型。内容分析得出了九个反事实的审计失败，分为四类。与“理想”模型相反，审计（a）未能通过曲解威胁的显着性来促进对威胁的准确理解，（b）未能充分解决已知问题的恶化问题，从而未能促进及时采取行动应对威胁，（c）未能促进问题的有效管理，导致审计目的和范围混乱，以及 d) 未能充分关注威胁，因为缺乏对关键危险的关注，而把重点放在操作问题上的文书工作上，或者在赞扬的同时错过了威胁，从而“默默地失败”表现。从业人员应根据这些标准严格评估审计，并确保审计有效识别早期预警信号。